Evolocumab improves survival before the first infarct, and voltage mapping earns its place

The edition in brief

VESALIUS-CV randomised 12,257 patients with qualifying atherosclerosis or high-risk diabetes but no previous myocardial infarction or stroke to evolocumab or placebo. Over a median 4.6 years, all-cause mortality was 20% lower with evolocumab (hazard ratio 0.80, 95% CI 0.70 to 0.91; 5-year Kaplan-Meier rates 7.9% vs 9.7%), with consistent direction for cardiovascular death (HR 0.79, 0.64 to 0.98) and non-cardiovascular death (HR 0.85, 0.71 to 1.01). Multistate modelling attributed 78% of the non-cardiovascular mortality signal to prevention of antecedent non-fatal events. IDEAL-AF randomised 209 of 936 screened patients with persistent atrial fibrillation and low-voltage zones of at least 3.0 cm² to adjunctive low-voltage zone ablation or pulmonary vein isolation alone. Freedom from atrial arrhythmia without antiarrhythmic drugs at 12 months was 67.6% versus 37.4% (difference 30.3%, 95% CI 17.4 to 43.2; odds ratio 3.5), with similar serious adverse event rates. NOTION-4 tested three months of a direct oral anticoagulant after transcatheter aortic valve replacement in 347 patients without an anticoagulation indication. Hypoattenuated leaflet thickening fell at three months (12.1% vs 31.8%) but the difference had gone by twelve (28.3% vs 32.2%, risk difference −3.9%, 95% CI −14.4 to 6.6). Death, stroke or major bleeding was higher with the anticoagulant strategy (8.2% vs 2.3%). The updated Cochrane review of exercise-based cardiac rehabilitation now covers 107 trials and 26,886 adults, with a high-certainty reduction in myocardial infarction (RR 0.72, 0.54 to 0.95). The FDA also recorded a supplement to a generic carvedilol application — administrative rather than a safety action.